Chronic Kidney Disease By Nicholas Ashley

Key Aims Causes of CKD What to ask in a history to get the diagnosis How to treat CKD and its complications

Definition Defined by the presence of kidney damage or decreased kidney function for three or more months, irrespective of the cause Causes of CKD HYPERTENSION DIABETES PCKD

Staging Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Kidney Damage with normal/increase eGFR>90 Kidney Damage with mildly reduced eGFR60-89 Moderately reduced eGFR30-59 Severely reduced eGFR15-29 Kidney Failure<15 KIDNEY DAMAGEPersistent Proteinuria/Microalbuminuria Persistent Haematuria Changes on Renal Imaging (Structural Abnormalities)

Detecting early CKD Spot Urine Albumin Creatinine Ratio>30mg/g

Presentation of CKD Urea: Anorexia, Fatigue, Gout, Pruritis, Confusion, N/V, Restless leg, Chest pain (pericarditis) Fluid: Oedema, Weight gain Acid: SOB Potassium: Palpitations, Syncope Vitamin D: Bony pains, Fractures EPO: Fatigue, SOB, Pallor B2 microglob: Peripheral neuropathy Anorexia Fatigue Pruritis Oedema Pains Numb feet N/V

Investigations Bloods: FBC U+E eGFR Bone Urate PTH Urine:Dipstick MC+S ACR Urinalysis Imaging:USS X-ray KUB 2 nd Line Investigations CT Abdomen Angiography Renal Biopsy

Management CONSERVATIVE Education (leaftlet and BKPA) Renal diet - Low fluid, sodium, potassium and phosphate Avoid renotoxic drugs (but keep ACEi) Cardiovascular Risk Factor addressing MEDICAL See Next Slide ESRF Haemodialysis Continuous Ambulatory Peritoneal Dialysis Transplant Remember to include any treatment for the underlying cause if there is one

EPO Low Ca High PO4 Low Ca High PO4 Bone Health Vit D Urea/Pru ritis Fluid DON’T FORGET CARDIOVASCULAR RISK FACTORS

Specific Treatments to Rote Learn CARDIOVASCULAR RISK +++ Statins, ACEi, Advice ANAEMIAEPO BP CONTROLACEi (not in RAS) OSTEOPOROSISBisphosphonates VITAMIN Dalfacalcidol/Calcitriol HYPOCA++Ca++ Supplements HYPERPO4-Calcium Carbonate OEDEMADiuretics, Fluid/Na restrict PRURITISCholestyramine RESTLESS LEGClonazepam Note these factors together lead to the parathyroid response responsible for renal bone disease

Renal Replacement Therapy CAPD “Peritoneum is used as a semi- permeable membrane” Instill 3L isotonic fluid 4x/day and allow 30mins for exchange NB: Infrequently add glucose to dialysate to remove water Haemodialysis NB: Uses serial weights to measure water removal PRO’sCOMPLICATIONS CheaperSBP More ConvenientPsychosocial issues Easy to teachHernia Infection PRO’sCOMPLICATIONS Less frequentA-V fistula needed Not DIYTransport to hospital Meet other CKD - support Dysequilibrium Syndrome Learn about complications (biopsychosocial) of renal transplant and immunosuppression

Implications for Junior Doctors: Not Many! (It is largely dealt with on an O/P basis as it is CHRONIC) BUT Keep in mind CRF when considering Contrast imaging Using renotoxic drugs Prescribing medicine doses Never go near an AV fistula (BP, cannula)

Summary Lots of complicated information Learn the small print at home For this session learn the key points Causes of CKD What to ask in a history to get the diagnosis (7 key Sx) How to treat CKD and its complications

Quick Recap Quiz 3 causes of CKD The three markers of KIDNEY DAMAGE in staging disease 7 key symptoms in history 2 conservative and 3 medical treatments The 3 renal replacement therapies Any Questions?

Case Scenario 58 year old man presents to his GP after his wife made him attend. He has been feeling generally unwell and lethargic for 6 months but has not sought medical attention until now. On further questioning he also reports that he has reduced exercise tolerance and feels nauseous. He also complains of itching which is resistant to piriton. He also complains of some generalised pains in his joints and back which is worse at night. He has also been more thirsty than normal. He has no significant medical history and is on no medication and has no known allergies. No remarkable family history is noted. On examination his blood pressure is 160/95. His skin is slightly yellow and his has excoriations from scratching. His Cardiovascular, respiratory and abdominal examinations are unremarkable. The GP orders some blood tests and then later that day refers him to the medical registrar on call when he finds that the patients renal function is deranged with Na 143, K 5.8, Urea 55 and creatinine 398. What are your main differential diagnoses for this man? i.e CKD and causes (make sure these include all important differentials that must be ruled out) How would you investigate him? What would your management plan be for him? What are the various stages of CKD? What are the complications of CKD? What types of renal replacement therapy are available?